Tuberculosis (TB) care

Biologics and immunotherapy

Treatment for rheumatologic, inflammatory diseases and other conditions puts your patients at risk for tuberculosis.

Patients on biotherapy are at risk for TB

Treatments using disease-modifying antirheumatic drugs (DMARDs), immunosuppressants and glucocorticoids have revolutionized the treatment of autoimmune diseases such as rheumatoid arthritis, Crohn's disease and psoriasis.

However, patients undergoing immunotherapy face an increased risk for tuberculosis. The immune system helps contain latent TB infection and prevent progression to active TB disease. One of the most common classes of DMARDs, TNF-α inhibitors, puts patients at a 9-fold increased risk of developing active TB (1).

To limit the risk of TB progression, global recommendations now include a screening test for TB infection for most patients receiving biotherapy (2–5).

What therapeutics can increase TB risk?
What therapeutics can increase TB risk?

TB testing is recommended prior to most immunotherapies used for rheumatologic and inflammatory diseases (2–6), as well as those used in oncology/hematology settings (7, 8). Global experts recommend screening prior to:

  • bDMARDs (TNF inhibitors)
  • tsDMARDs (JAK inhibitors)
  • csDMARDs (methotrexate)
  • Interleukin inhibitors
  • Immunosuppressants
  • Glucocorticoids
    • Immune checkpoint inhibitors
    • Monoclonal antibodies
Which of your patients requires TB screening?

Global guidelines and pharmaceutical labeling requirements reinforce that TB testing is critical when evaluating your patient’s treatment options. These treatments extend beyond use in rheumatology, impacting gastroenterology, dermatology and cancer treatment.

In addition to identifying an immediate risk of TB reactivation during primary treatment, TB screening prior to immunotherapy provides you with flexibility as your patient ages and progresses to new medications.

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Reduce the risk of future complications

In addition to screening for TB at the onset of immunotherapy, retesting every 1–2 years for patients who have a new or recurring risk factor should be considered. Risk factors include living in or extended travel to an endemic country, TB exposure, or employment in a healthcare or congregate setting. Risk factors such as smoking, substance use disorders, diabetes, etc. should also be considered.

What test should you use for TB screening?

The WHO states that TB blood tests (IGRA) can be used interchangeably with the tuberculin skin test.

The latest EULAR guidelines further state that IGRAs are the preferred test for patients with autoimmune disorders for their performance and ease of use. TB blood tests are:

  • Accurate
  • Single visit
  • Unaffected by the BCG vaccine
Choose modern testing for your at-risk patients
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References:
  1. Lobue, P. and Menzies, D. Treatment of latent tuberculosis infection: An update. Respirology. 2010;15: 603-622.
  2. 2. Lewinsohn DM, et al. Official ATS/IDSA/CDC clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017;111-115.
  3. US CDC. Updated guidelines for using Interferon Gamma Release Assays to detect Mycobacterium tuberculosis infection — United States, 2010. MMWR 2010; 59, RR-5.
  4. World Health Organization. WHO consolidated guidelines on tuberculosis: tuberculosis preventive treatment. 2020.
  5. Fragoulis, GE, et al. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2022;0:1–12.
  6. Diel, R, et al. Joint Statement (DZK, DGRh, DDG) on the Tuberculosis Risk with Treatment Using Novel Non-TNF-Alpha Biologicals. Pneumologie. 2021;75: 293–303
  7. Anastasopoulou, A, et al. Reactivation of tuberculosis in cancer patients following administration of immune checkpoint inhibitors: current evidence and clinical practice recommendations. J Immunotherapy Cancer 2019;7:239.
  8. Lin, C, et al. Tuberculosis infection following immune checkpoint inhibitor treatment for advanced cancer: a case report and literature review. Front. Immunol. 2023;14:1162190.